MALARIA ELIMINATION IN ZANZIBAR - Soper Strategies

all levels. This includes communication to prospective tourists
through brochures (in collaboration with major all travel agents
in Europe and North America), information on achievements
and the reasons for taxation in media such as in-flight magazines,
billboards and flyers at the point of entry, and even promotion
of the malaria elimination program (and fundraising) in hotel
brochures.
DECENTRALIZATION
The proposed organizational charts do not provide details on
decentralization other than positions needed on both islands.
However, we strongly suggest decentralizing responsibilities,
wherever possible and appropriate, to the relevant levels (island,
district or even Shehia). This does not mean that every single
unit should be represented at the district level, and we strongly
argue against decentralization for the sake of decentralization.
Geographical access in Zanzibar is very good with a road network
that reaches most villages. For certain units decentralization to
the island level will be sufficient while others might want to
decentralize to the community level to increase community
awareness and ownership. We suggest discussing this in more
detail with all stakeholders once all activities for the elimination
program have been fully defined.
EQUIPMENT
A full assessment of the ZMCP’s assets (and future funding to
buy equipment) has not been done for this feasibility exercise,
and the recommendation below only discuss major needs in
terms of equipment for some of the proposed departments.
We propose to strengthen the ZMEP in terms of IT so that all
databases can be easily shared between departments and secure
backups ensured. The set-up of a central database in the M&E
unit will require high processing power and sufficient memory
capacity not only for the central server but also for the individual
computer units. All necessary licenses should be bought to
guarantee high quality and legal software packages not only to
run and protect (anti-virus, firewalls) the server but also for GIS
and any audiovisual/publishing needs.
The surveillance and response unit will need their own transport
means at any given time in order to react immediately when
a case is identified. The unit will also be responsible for QA/
QC and will, as per the proposed algorithm in the HSS chapter,
need a PCR unit with all necessary reagents and maintenance
equipment. In addition, quality control of microscopy slides and
training of microscopists will remain important. The ZMEP will
need to assess how far their current set-up is sufficiently equipped
to execute these tasks. The same will need to be done for the
entomological department.
INFRASTRUCTURE
The infrastructure of the ZMCP is currently being upgraded, and
it is unclear in how far the program will be able to accommodate
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the staffing proposed. It is likely that the set-up of a laboratory
with PCR capacity might require adaptations to existing
infrastructure and/or building new rooms. We propose to do a
full assessment once the current construction is finished and the
set-up of the elimination program agreed upon.
COMMUNITY INVOLVEMENT IN MALARIA
ELIMINATION
INTRODUCTION
In recent years, there has been growing consensus among the
global malaria community that approaches that engage the
communities they target (community-directed intervention or
CDI) are essential to the achievement of treatment and prevention
targets (WHO/TDR, 2008). Such approaches will be even more
important for elimination programs than for control. With a
high burden of disease and a short period of implementation, it
may be possible to have communities accept interventions they
don’t fully support. For an elimination program, however, it will
be very challenging to achieve and sustain the necessary levels of
coverage at low levels of disease if communities do not support the
goal and approach. As discussed in the legal section, attempts to
force compliance with interventions are discouraged and may be
counterproductive, reducing support for the elimination program.
In contrast, if communities feel ownership of and engage in the
elimination activities, many key activities will be easier to
implement and coverage targets more likely to be achieved.
Community involvement is not a science, but rather must be
carefully designed to fit the mores and conditions within each
country and area. As such, relatively little central guidance exists
on specific approaches to community involvement in malaria
control and elimination programs. This does not diminish its
importance, and in this chapter we consider the role of community
involvement in a potential elimination program on Zanzibar.
THE ROLE OF COMMUNITY INVOLVEMENT
Participation is often used to denote the community’s simple
acceptance of actions that are being presented to–and sometimes
forced upon–them. This chapter uses an alternative definition that
considers participation as a process of community involvement
in the planning, organization, operation, and control of health
activities (WHO, 1984). With this approach, community
members play an active and direct role in project development and
are involved in a range of relevant decisions, including distribution
of health services and tools (e.g., drugs, diagnostics and preventive
measures). There is a shift away from monolithic power resting
with central decision-makers to allowing communities to play a
meaningful and substantive role. Within the paradigm of structural
participation, some distinguish between “direct participation” and
“social participation”. The former relates to the mobilization of
community resources for the implementation of priorities that have
been defined by the formal health system, while the latter refers to
community involvement in setting priorities for what disease and
intervention priorities to pursue (WHO/TDR, 2008). The latter is
ideal and should be striven for but may not always be feasible.